What Does Lichtman Stage IIIC Mean for Kienböck Treatment?

When your surgeon tells you that you have Lichtman Stage IIIC Kienböck disease, it means that your lunate bone has developed a specific type of break called a coronal fracture ^[1]. A coronal plane fracture means the bone has split to separate the palm-side (volar) and back-of-wrist (dorsal) portions of the lunate ^[1]. In earlier stages of Kienböck disease, the bone loses its blood supply and may weaken or collapse, but it does not have this specific split. This makes your case more complicated because the surgeon is dealing with a physically fractured bone that can destabilize the rest of your wrist ^[2]. Because this is a complex and rare stage, it is highly recommended to seek an evaluation (or a second opinion) from a hand-and-wrist specialist familiar with Kienböck disease.

What Stage IIIC Tells You—and What It Does Not

It is important to understand what this label means for you:

• It is an imaging finding: Stage IIIC describes the physical fracture pattern seen on your scans ^[1].
• It does not predict your exact pain or function: The stage alone does not tell the surgeon how much pain you are in or dictate a single mandatory operation ^[3].
• It is a guide, not a rule: Treatment decisions depend on many factors, including your age, your symptoms, the health of your wrist cartilage, and your personal goals—not just the stage ^[3].

Why a Coronal Fracture Complicates Treatment

The lunate acts as a central keystone in your wrist. When a coronal fracture occurs, it is considered a poor prognostic marker (a sign that the disease may progress and worsen) because the break can compromise the bone’s structural integrity ^[2]. This fracture pattern can make saving the lunate more difficult, but it does not completely determine your individual outcome.

When the lunate splits, two structural changes may follow:

• Bone Migration: The capitate—a bone situated just distal to (below) the lunate, closer to the fingers—can migrate proximally into the collapsing lunate space, which disrupts the mechanics of the wrist ^[2].
• Carpal Malalignment: Neighboring bones, such as the scaphoid, may shift out of their normal position (a process called subluxation) ^[4]. This changes how your wrist bears weight.

How Stage IIIC Changes Your Treatment Options

There is no strict algorithm for treating Stage IIIC. Management is highly individualized. For some patients with very mild symptoms, observation or temporary non-surgical care (like splinting and modifying activities) might still be appropriate ^{[5] [3]}. However, if surgery is needed, the presence of a coronal fracture generally focuses the treatment discussion on either specialized reconstructive fixation or a salvage procedure ^[6].

1. Specialized Lunate Preservation (Fixation)
If the fractured pieces of the lunate are large enough, not overly shattered (comminuted), and the surrounding cartilage is healthy, your surgeon may attempt to save the bone ^[7]. Surgeons may use one or a combination of the following techniques:

• Internal Fixation: Using specialized headless compression screws to piece the fragments back together ^[7].
• Bone Grafting: Bringing in healthy bone (sometimes with its own blood supply) from another area to promote healing ^[8].
• Unloading Procedures: Cutting a nearby bone (like the radius) to relieve physical pressure on the lunate while it heals ^[9].

While preservation is the goal, these procedures are technically demanding ^[6]. The bone does not always heal properly (a risk known as nonunion), and some patients may eventually require further surgery ^[6].

2. Salvage Procedures
If the lunate is too fragmented to fix, or if the cartilage in the wrist is already damaged by arthritis, surgeons typically recommend a salvage procedure ^{[6] [3]}. “Salvage” means the goal is to preserve useful wrist function and reduce pain, rather than trying to restore the original anatomy.

• Proximal Row Carpectomy (PRC): This involves removing the entire row of bones that includes the scaphoid, lunate, and triquetrum ^[10]. The wrist then hinges on the remaining bones. This requires the cartilage on the capitate head and the radius bone (the lunate facet) to be perfectly healthy ^[11].
• Limited Intercarpal Fusion: Joining specific wrist bones together (such as a scaphocapitate fusion) to bypass the damaged lunate and stabilize the wrist ^{[12] [13]}.
• Total Wrist Fusion: If arthritis is extensive, fusing the entire wrist joint can provide stability but eliminates wrist motion ^[14].

While salvage procedures can improve pain and function, outcomes vary. Risks include residual pain, stiffness, permanent loss of some grip strength and motion, hardware problems, or the progression of arthritis ^{[6] [3]}.

Comparing Surgical Options

The Role of Advanced Imaging

Because a coronal fracture completely changes the surgical approach, your evaluation will rely on multiple types of imaging. Standard X-rays remain important for assessing overall wrist alignment and collapse ^[15]. A CT scan is highly useful for providing a 3D view of the fracture’s size, shape, and fragmentation ^{[15] [16]}. An MRI may be used to assess the bone’s viability and whether it still has blood flow ^[17]. Finally, wrist arthroscopy (using a tiny camera inside the joint) allows the surgeon to directly look at the health of your cartilage surfaces before making a final surgical decision ^{[11] [18]}.